Substance use treatment: Cognitive behavioural therapy and other options
SelfTherapy / 16 min readRemember how years ago substance use was called ‘addiction'? The World Health Organization concluded in 1964 that the term ‘addiction' was not a scientific term and substituted it with “drug dependence'. According to the WHO, the harmful or hazardous use of psychoactive (any substance affecting the mind) substances can lead to a dependence syndrome (which we commonly understand as addiction) that includes:
- a strong desire to take the drug
- difficulties in controlling its use
- persisting in its use despite harmful consequences
- a higher priority is given to drug use than to other activities and obligations
- increased tolerance
- sometimes a physical withdrawal state
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Adolescence is one of the riskiest times for picking up harmful habits. It's the age where there seems to be an increased desire to experiment but often not enough wisdom to choose wisely. The “feel good” factor and peer pressure govern many actions. So there isn't much room for self-regulation or delaying gratification. A desire for the continued state of pleasure, a momentary feeling of invincibility, or an environment that encourages substance use makes it hard to stop after a few “hits”.
The most commonly used substances are alcohol, tobacco, marijuana (cannabis) and opioids (to a small extent). Many studies also indicate that cannabis is a common substance of use during adolescence among school and college-going students, street children and working adolescents. The most commonly used opioids are in the form of buprenorphine and codeine in cough syrups. Here are some statistics:
- In India, about 20 million children ranging from 10-14 years were estimated to be tobacco addicted. About 5500 new users are added every year.
- 3.8% of children were smokers, while 11.9% were using smokeless tobacco.
- About 3% of children and adolescents between 12 to 18 years used cannabis and only 4% of adolescent substance users in India go for treatment of the problems arising from it.
Types of substance use disorders
There are two groups of substance use disorders according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013):
- Substance use disorders: These are the patterns or clusters of symptoms resulting from the use of a substance that you continue to take, despite experiencing personal, social, health, or occupational problems as a result.
- Substance-induced disorders: These include intoxication, withdrawal, and other substance/medication-induced mental disorders like short-term memory and learning, impaired ability to focus, poor coordination, paranoia, mania, analgesia, feelings of dysphoria, flushing of the face, itchy skin, dry mouth, etc.
Signs and symptoms of substance use
Here are the diagnostic criteria for substance use disorders according to DSM 5, which explains all the signs and symptoms of substance use disorders:
- The substance is often taken in larger amounts and/or over a longer period than the patient intended.
- Persistent attempts or one or more unsuccessful efforts made to cut down or control substance use.
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
- Craving or a strong desire or urge to use the substance
- Recurrent substance misuse results in a failure to fulfil major role obligations at work, school, or home.
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
- Important social, occupational or recreational activities given up or reduced because of substance use.
- Recurrent substance misuse in situations in which it is physically hazardous.
- Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance, as defined by either of the following:
- Markedly increased amounts of the substance in order to achieve intoxication or desired effect;
- Markedly diminished effect with continued use of the same amount;
- The characteristic withdrawal syndrome for the substance;
- The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
Understanding the link between substance use and mental health
Substance use and mental health are very closely interconnected. A lot of times people develop a dependence on a substance to escape emotional or physical pain. Children from broken families and abusive childhoods are more likely to use psychoactive substances. A correlation has also been found between low self-esteem and substance use.
Dependence on a substance seems to be a coping mechanism known as ‘avoidance' where the person seeks comfort in the haze or ‘high' provided by these substances to avoid dealing with life. Once dependence develops, it leads to a lot of co-morbid mental illnesses like depression, bipolar disorder, anxiety disorders, and even psychosis. According to DSM-5, substance use disorders lead to cognitive function loss, irritability, anger issues, and difficulties with concentration and focus. In addition, substance misuse leads to work absence and problems in interpersonal relationships which in turn leads to further emotional problems.
⚠️If you or someone you know is having suicidal thoughts, help is at hand. Please visit this list of helplines and resources for different countries.
Substance use and mental illness treatment
Treatment for substance use has to happen across many levels, sometimes simultaneously. The treatment aspects are:
- Management of withdrawal symptoms during detoxification
- Management of cravings and relapse prevention after detoxification
- Medications to substitute psychoactive substances to facilitate weaning off
- Medications to manage and treat comorbid psychological disorders like mood and anxiety
- Behavioural counselling
- Psychotherapy
- Modification of family and community environment to reduce cues that induce cravings
3 Psychotherapeutic techniques for substance use treatment
Treatment for substance use is a large-scale effort that involves many aspects of the patient as well as his/her environment to ensure continued relapse prevention or avoid any related in behaviour. The first step of any type of addiction treatment usually involves admission to a de-addiction centre for a detoxification period where the patient is monitored during withdrawal and sometimes managed with pharmacological aids to ease the physical discomfort and pain. After detoxification, depending on the substance being used, the patient is started on a substitute medication regime.
Psychotherapy and counselling sessions are begun to build healthy coping skills and management of cravings. Group therapy has been found to be especially helpful in such cases because the patient finds resonance in fellow users and it helps to build a support system for him/her. Family counselling is also utilised to explain enabling (to unknowingly maintain addiction behaviour at home by skirting around the issue), codependency or denial behaviours, and also to psychoeducation about the process of addiction so that the family members can create a conducive environment for the patient's recovery. Some commonly used psychotherapeutic techniques for the treatment of substance use are as follows.
1. Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is a form of psychotherapy that is based on the belief that thoughts, emotions, physical sensations and behaviours interact with each other, and thus changing negative thoughts or behaviours can lead to improvements in mental state. It is used to treat a wide range of issues from common mental health disorders such as depression and anxiety to substance use dependence.
How does cognitive behavioural therapy work?
CBT attempts to identify negative thought patterns and/or unhelpful behaviours that may be contributing to a person’s difficulties. In therapy, clients learn how to challenge negative thoughts and beliefs and replace them with more positive or balanced views, and/or how to switch out unhelpful behaviours and coping strategies with more helpful ones. Treatment may also include skills training such as breathing techniques to enable better management of anxiety inducing situations. With the help of exercises done within the therapeutic space and as “homework” outside of sessions, the goal is to ensure that the individual can develop healthy patterns of thinking and behaviours, and use the tools that they have learned during therapy to maintain their progress in the longer term.
How are cognitive behavioural interventions used in substance use treatment?
The negative thoughts and emotions that a person may experience can cause them to feel overwhelmed and often to cope with this, they may choose to engage in alcohol consumption or substance use.
To treat addiction, CBT is used to identify the triggers that lead a person to engage in these unhealthy behaviours and helps to learn the skills required to better manage these triggers in the future, thereby helping them to actively work on choosing healthy behaviours to function. Depending on what suits the client best, there are a number of strategies that can be explored to work through, such as thought challenging, journaling, relaxation techniques, exposure therapy and cognitive restructuring.
The mental health app Wysa contains numerous self-help tools and exercises based on CBT techniques which can be used alongside treatment. These can serve as substance use therapy that can help build coping skills over time.
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How effective is cognitive behavioural treatment?
Supporting research states that CBT is a helpful strategy to use both by itself and in combination with other therapeutic strategies. CBT is commonly used to treat addiction and substance dependence concerns owing to its high efficacy to help clients through the recovery period by working on eliminating negative behaviours and promoting healthy behaviours and helps in relapse prevention.
2. Motivational Interviewing
This technique encourages individuals to make positive and firm decisions toward recovery. It forms a pathway for growth by taking people forward from a place of indecision or uncertainty. The primary principles used are empathy and support. This technique has proved to be very useful in the treatment of substance use in a psychotherapeutic way because it targets the three major roadblocks to substance use recovery, which are:
- Readiness
The motivational interviewing technique explores whether the patient is psychologically ready to make a change. It also deciphers at what stage they are because readiness can shift from time to time. The motivational interviewing technique encourages people and increases their resilience towards acceptance of the change.
Ambivalence
This implies the patient's mixed feelings about making a change because they struggle between the relief they get from the substance use and the harmful effects it has on their life. The motivational interviewing technique can ease the confusion and constant battle in the minds of the people and help them stay focused on their path of recovery.
- Resistance
This refers to the internal resistance the patient feels towards effective change because of internal as well as external factors (“I want to do it but I can't”). The motivational interviewing technique has been found to be especially effective with alcohol use and smoking.
3. Psychodynamic therapy
This technique attempts to unearth the unconscious or suppressed motives behind addictive behaviours, the defence mechanisms used to uphold those behaviours and resolve any deep-rooted conflicts.
Most of the time, early life experiences give rise to deep-seated unconscious conflicts within an individual which are too painful to be kept at the surface. So they get suppressed and certain defence mechanisms are utilised to keep the anxiety arising out of those internal conflicts at bay. People sometimes turn to substance use as a way to avoid dealing with those suppressed conflicts. Psychodynamic therapy can help to gradually bring those repressed thoughts to the surface and re-integrate them with the patient in the present. This helps unresolved emotions and past guilt or shame to be dealt with and the need for substance use to suppress those emotions fade away.
Conclusion
There can be many reasons for a substance use disorder, ranging from a personality disorder, early exposure to trauma, and family conflict, to psychological vulnerability. It needs to be treated as an illness and the patient should not be assumed to be acting voluntarily. If the perpetuating and maintaining factors are handled practically and continuous healthy support and monitoring are provided, it can yield some very promising results in the recovery.
Commonly asked questions about substance use
Which health problems can substance use cause?
Substance use can cause many behavioural as well as health problems. Substance use can lead to depression, anxiety, mood disorders, and even psychosis. It can suppress the nervous system, lead to cardiovascular, liver and kidney disease and exacerbate existing health problems like blood pressure and diabetes. Along with individual impact, substance misuse also leads to interpersonal problems and family discord.
How common is substance use disorder?
Around 1.5% of the global disease burden results from alcohol and illicit drug addiction; in some countries, it's over 5%. In fact, More than half of those who die from alcohol or drug overdoses are younger than 50.
What are the various forms of substance use?
Substances can be consumed by ingestion, inhalation or injection. The most commonly used substances are alcohol, cannabis (bhang, ganja), stimulants (cocaine), opioids (heroin) and pharmaceuticals like sedatives.
How can you identify a substance user?
The Diagnostic and Statistical Manual for Mental Disorders lists the symptoms to be able to diagnose people with substance use disorder. But, here are some observable signs that can help you identify someone using a substance: erratic sleep cycles, redness in the eyes and allergy-like symptoms, irritability, secretive and avoidance behaviour, injection marks on various parts of the body like arms and feet, flaring temper, and stealing money or accumulating debt.
What comes first: substance use or mental health problems?
This is a classic chicken and egg situation. In the case of substance use, both scenarios can be true. Someone suffering from an anxiety disorder or depression might turn to a substance to seek comfort and eventually become dependent. On the other hand, someone who becomes dependent on a substance might develop a psychological illness as an after-effect.
What is the difference between substance use disorder and addiction?
There is no difference between the two. “Addiction” is a medically outdated term used earlier to describe substance use disorders. This term was declared unscientific by the World Health Organization in 1964.
Is substance use causing you harm?
Yes, substance use harms you physically, socially, professionally and personally. Like other mental illnesses, this impacts all aspects of life. It leads to deterioration of cognitive function, damages the liver, heart, and kidneys, creates conflict in the family, causes absence from work, and distances you from friends and colleagues.
Is addiction a choice or a disease?
Addiction is a psychological and physical dependence on a substance and therefore illness. It may start as a voluntary ‘experiment' to try certain substances but once dependence develops, it becomes a psychological illness with actual physical and neural correlates. Therefore, persons suffering from addiction must be treated as ill, provided proper medical and psychological assistance and not expected to just recover using sheer willpower.
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Photo by Polina Zimmerman